Muscoskeletal conditions [completed] Flashcards
What is the role of the muscle tendon in the joint?
Attaches the muscle to the bone
What is the role of muscle in the joint?
Contracts and relaxes to create movement. Working alongside the tendon
What is the role of the ligament in the joint ?
The ligament is bands of tissues that connect bones together to give the joint strength and stability. It prevents abnormal movement.
what is the synovial bursa and what is its role?
Small fluid filled sacs that reduce friction to protect the tissue it lies between. Less friction = less wear and tear
Where can a synovial bursa be found?
Between:
two tendons
a tendon and skin
skin and bone
tendon and bone
What is inflammation of the bursa called?
bursitis
What are some causes for inflammation, swelling and pain in muscoskeletal conditions?
Wear and tear (age-related?)
Strain (unaccustomed use)
Overuse (acute or chronic)
Trauma (Acute)
What is important to establish when assessing symptoms in common muscoskeletal conditions?
If it is due to acute or chronic disorder.
- Look at history and patterns
- Usually an obvious cause if acute (e.g. sports injury) whereas chronic causes are harder to establish
What can systemic symptoms alongside joint symptoms suggest?
Inflammatory or chronic conditions - aura, prodromal symptoms like fever and fatigue common with RA and gout
What are common causes of neck pain?
Strain on ligaments and muscles from unaccustomed movement or positions such as lifting wrong or being sat at a desk all day
What are some example of common conditions that affect the neck?
Wry neck (Acute torticollis)
Prolapsed disc
Arthritis
What is wry neck (ACUTE TORTICOLLIS)?
When the neck only hurts when moved in a certain way. It is usually self limiting (1-2 days) and presents in people with no history of neck problems
What causes wry neck?
The neck being bent or twisted and muscle is spasming. -> often when a person sleeps weird, turns too quickly or going suddenly from hot to cold weather
How does arthritis in the neck present?
Equally painful on BOTH sides of the neck but CAN be one side. Gradual onset as usually due to wear and tear.
What is capsulitis (Frozen shoulder) ?
Inflammation of the supporting tissue (tendons) in the shoulder
What is the cause for capsulitis?
overuse or unaccustomed movement
How does capsulitis present?
Pain and restricted movement in one or all directions
Why may there still be restricted movement after the shoulder has healed from capsulitis? How long can this last?
Tissue scarring and fibrosis of the muscles and tendons due to chronic overuse. Movement restriction can be permanent.
What are the two sections of the upper back called?
Cervical and thoracic
What are the three sections of the lower back called?
Lumbar
Sacral
Coccyx
What would need to be excluded if a person is presenting with pain in the thoracic area and how?
Cardiovascular causes so look for:
- history of heart problems
- angina
-what kind of pain? radiating could be heart attack
- pallor, and sweaty
What could cause pain from straining of intercostal muscles between the ribs?
- Coughing
- lifting heavy items from back instead of from legs
What would strains/muscle tears in the upper back feel like?
sharp pains in a defined area that worsens when breathing in and coughing. person may feel discomfort when eating.
What should we do if a person’s breathing is affected AND they have a sharp continuous pain in their chest?
REFER - may be a pulmonary embolism
What is lumbago?
pain of the lower back
What is the cause for mild lumbago?
strain of spinal muscles and ligaments
What are the causes for severe lumbago?
Vertebrae, disc and associated joint disorders
What age group is lumbago most common in?
People in their 30s and 40s
Do patients with lumbago experience pain at rest or on slow movement?
No
When should lumbago be referred?
If lasting over 3-4 weeks
What are the discs in between veterbrae?
Disc are circular pads of tissue that are gel on the inside and have a tough outer casing. They minimise friction between vertebrae.
What is a herniated/prolapsed disc?
When the disc between the vertebrae shape changes and the gel pushes through on the outer casing. This causes impinging on the nerve root.
What are the signs of a slipped disc?
Sudden severe back pain
Stiff gait
Pain when sitting or at rest
Referred pain due to impingement on nerve roots
What is the most common nerve affected by slipped discs?
Sciatic nerve - nerve that goes from lower back into leg
What is sciatica?
Impingement on sciatic nerve causing referred pain in the leg.
According to NICE guidelines when should sciatica be suspected?
- Pain in one side/legthat goes below the knee
- Lower back pain not as intense as leg pain
- Numbness, tingling , parastheia and muscle weakness
How long does sciatica take to settle?
4-6 weeks but may take longer in some patients
What is the first line drug management for sciatica?
Ibuprofen or naproxen with a PPI
What is the second line drug management for sciatica?
codeine with or without paracetamol but opioids should be avoided where possible
Should paracetamol be offered alone for sciatica?
NO
What is some self management advice that can be given to patients with sciatica?
- HEAT: hot water bottles, heat patches
- Place a small firm cushion between knees when sleeping on the side or propping the knees up with a pillow if lying on the back
- Simple exercises
- Staying active, resume normal activities and work as soon as possible
What is ankylosing spondylitis?
Inflammatory arthritis of the lumbar spine and joints in the SACRAL area.
When does ankylosing spondylitis typically present?
Young adulthood
Is there a genetic factor to ankylosing spondylitis?
Yes
Is ankylosing spondylitis more common in males or females?
males
What can we ask a patient presenting with ankylosing spondylitis symptoms to confirm likelihood?
If their parents, especially their father had similar symptoms
True or false. Ankylosing spondylitis gets better after rest.
False. Gets worser and stiffer after rest especially right after waking up but improves with exercise
What can happen over time in ankylosing spondylitis?
There is inflammation of the ligaments and calcification where ligaments attach to bones in the spine so the vertebrae begin to fuse.
What is coccygitis?
Pain in the coccyx.
What is the usual cause for coccygitis?
A fall on a hard place such as slipping on an ice rink
What symptoms would a person with coccygitis present with?
Pain
Tender to tocuh area
Sitting down is difficult
What can be provided to patients that have difficulty sitting due to coccygitis?
Special ring shaped cushion that there is less pressure on the coccyx
How long does coccygitis take to heal?
A few weeks - seek further guidance if longer
What are some differential diagnoses that have to be ruled out in lower back pain?
Pyelonephritis/UTI: temperature, fever, urinary symptoms?
Issues with gut: Changes in bowel habit and weight loss
Persistent lower back pain + unexplained weight loss in middle age - malignancy?
Why do we have to be careful in patients presenting with back pain who have a history of cancer?
If in remission and they have lower back pain it could have come back in the bone
What is tennis elbow and golfer’s elbow?
Straining of tendons in the forearms due to overuse and unaccustomed movement (gripping na pulling actions)
What is tennis elbow?
Pain on the outside of the forearm due to a tear in the outer muscle or tendon due to pulling motion when playing tennis
What is golfer’s elbow?
Pain on the inside of the forearm due to a tear in the inner muscle or tendon due to gripping action when playing golf
What is the usual duration for tennis elbow and golfer’s elbow?
Depends on person but condition usually resolves with rest.
When should tennis elbow and golfers elbow be referred?
If it lasts over 2-3 weeks
What can a person due to prevent reinjury after tennis elbow or golfers elbow?
use a support
What is bursitis or student’s elbow?
Pain ad tenderness over the tip of the elbow due to bursa being inflamed.
Why do students commonly get bursitis of the elbow?
Repeated flexing of the elbow or persistent leaning - from resting on desk.
When is there pain during student’s elbow?
On rest and on movement
What is housemaid’s knee?
Bursitis of the knee caused by kneeling a lot
What is carpal tunnel syndrome?
Inflammation of the carper tunnel causing compression of the median nerve
What is the carpal tunnel
Transverse ligaments that nerves go through
What is the median nerve?
the one that goes down the middle of the wrist
What is the most common disorder of the forearm, wrist and hand?
Carpal tunnel syndrome
What are the symptoms of carpal tunnel syndrome?
Pain, tenderness and numbness over the inside of the forearm, palms, wrist and fingers
Can carpal tunnel syndrome be managed long term in community?
No
How can carpal tunnel be managed?
Wrist support
Steroid injection
Surgery
How does a wrist support help with carpal tunnel syndrome?
Wrist is supported by a rigid metal spine that keeps hand at a neutral angle without apply force on the carpal tunnel - may recover in a few weeks
How does a steroid injection help with carpal tunnel syndrome?
reduces inflammation
How does surgery help with carpal tunnel syndrome?
Cutting ligaments to ease pressure as the nerve has more space. If carpal tunnel is in both hands each hand is done one at a time.
What are the most common causes for pain in the upper leg?
Pain from sciatica
Sports injury due to strain or rupture of thigh muscles - heals quickly with rest
What are some common conditions of the knee?
Bursitis:
Front of knee (Housemaid’s knee)
Back of knee (Baker’s cyst)
Sports injury due to strain or rupture of thigh muscles or just below knee - heals quickly with rest
What are some common conditions that can affect the lower leg/achiles tendon?
Sports injury resulting in rupture of the tendon
What happens in complete rupture of the achilles tendon?
Person cannot walk on the affected foot
What happened if the achilles tendon is partially ruptures or inflamed (tendonitis)?
Difficulty standing on tiptoes or wearing heels
Are injuries of the Achilles tendon very painful?
Yes
Do conditions of the lower leg/achilles tendon need to be referred?
Yes
What are the most common causes of conditions of the ankle?
Sports/activity related injury caused by a strain
Why would an X-ray be needed to figure out the severity of an injury in the ankle?
It can sometimes be difficult to tell between a sprain and a fracture
What is the difference between a sprain and strain?
Sprain is overstretching or tear of ligament
Strain is a stretch or tear of muscles and tendon
Are sprain and strain used interchangeably?
Yeah
What are the common conditions that cause pain in the foot?
Bursitis at the back of the heel
Pain under the heel can be caused by bursitis or plantar fasciitis (policeman’s heel)
What is plantar fasciitis (policeman’s heel)?
Pain under the heel and the sole caused by the arch ligaments becoming stretched or damaged
What can worsen and relieve pain in plantar fasciitis?
Relieved on rest and worsened on tiptoe
Who is plantar fasciitis common in?
People who stand or walk a lot such as policemen
What can be given to relieve pain in plantar fasciitis?
Orthotic insoles which support the heel arch and ligaments.
GP or physio may reccomend stretches
What should be done if plantar fasciitis persist for more than 6 weeks?
Patients should be referred for more rigorous physiotherapy or steroid injections
What is bruising?
Bleeding below the skin after a fall, trauma or blow
Why do we have to establish a pattern for bruising?
Need to see if is is recurring or unexplained If there is an obvious cause it is likely acute and one off. If it occurs often at slight contact we need to consider why
When should bruising resolve?
Pain subsides after a few days and skin discolouration after 2-3 weeks
What drugs can cause bruising as a side effects?
Aspirin
Anticoagulants
Corticosteroids
Methotrexate
What are some warning signs in bruising that would warrant referral?
Unexplained, frequent or excessive bruising
Known clotting issues
Hepatic impairment
Taking warfarin, NSAIDs, steroids or carbimazole etc
When should patients presenting with muscle pain or bruising be referred?
Fracture/deformities
Pain at rest or worsened at rest
Severe pain and tenderness
Cannot bear weight and widespread or worsening
Immobilised joint
No response to treatment and no obvious improvement in 5-7 days
Gait disturbance
Bowel or bladder problems
Weight loss
Numbness or tingling
Elderly or children
Sings of infection
Who can we refer people presenting with warning signs to?
GP, walk in centre or A&E depending on severity and urgency vs need for investigations
What medicines may cause adverse effects that present as a sport/activity related injury?
Statin - myopathy and rhabdomyolysis
Ciprofloxacin- risk of tendonitis and tear and rupture of achilles tendon. Contraindicated in previous history of tendons issues after taking ciprofloxacin.
Analgesics - can MASK pain
Captopril and immunosuppressants - risk of arthralgia and myalgia
Drugs that increase risk of bleeding or bruising
What is the aim of treatment in acute injuries?
Reducing bleeding, swelling, pain and tenderness
What is the aim of treatment in chronic injuries?
Minimise symptoms, prevent further injury or progression
What should we promote in the first 72 hours of injury?
PRICE
Protection
Rest
Ice the area for 20 mins multiple times a day
Compression - binding to decrease fluid in space so less swelling
Elevation - above heart - using gravity to draw blood away
What should we tell a patient to avoid inn the first 72 hours of injury?
HARM - these increase blood flow by promoting vasodilation
Heat
Alcohol
Running - rest to promote healing
Massage
What is the aim of promoting PRICE and avoiding HARM
reducing swelling and inflammation by reducing blood flow to the area and promote healing
What is the advice on moving an injured joint?
NICE:
Avoid. In severe sprains and strain immobilisation for a few days may be needed.
Patient should start active mobilisation and flexibility exercises as soon as tolerated
PATIENT.INFO
Do not stop moving. Gently move the joint around so it can move in normal directions and to prevent stiffness
What is first line in the management of sports/activity related injuries?
Paracetamol with a topical NSAID such as diclofenac gel.
NSAIDs should only be started 48 hours after injury and oral NSAIDs should not be used alongside topical NSAIDS
When may rubefacients/counterirritants be used?
72 hours after ACUTE injury but in CHRONIC injuries time applied does not matter
What do rubefacients/counter irititants/antirheumatics do ?
rubiefacients cause redness and warming of the skin by producing local vasodilation Counter irritants contain capsaicin menthol or camphor.
They block pain signals and are massaged in to enhance effect and disperse pain mediators.
What are some examples of rubefacients/counter irritants?
Methyl salicylate in DEEPHEAT (wintergreen)
nicotinates
capsaicin
turpentine oil
camphor
menthol such as DEEPFREEZE
What advice should patients be given on the application of rubefacients and counter irritants?
Take care to avoid eyes/mucous membranes and broken skin.
Wash hands throughly after use.
What supports can be offered for injured joints?
Tubigrip
Easticated bandages
Neoprene supports
What is a tubigrip?
Long tubular bandage for ACUTE INJURIES.
Can be reused in the future
What type of injuries would elasticated supports and neoprene be used in?
Chronic conditions or to prevent further injuries. Made for specific joints - e.g. one product for knee, one for elbow etc
What is the benefit of using compression supports such as neoprene?
manual and mechanical control of temperature of injury to prevent further injury
What are the management options for bruising
Heparinoid
Arnica
Witch Hazel
How does heparinoid work?
Disperses oedema by inhibiting hyaluronidase. Hyaluronidase increases extravasation and causes swelling and bruising so this is prevented.
When should heparinoid be avoided?
If there is a possibility of infection - e.g broken skin
What is arnica?
A traditional herbal medicine product that is available as a homeopathic preparation. It reduces bruising and swelling.
How much evidence is there to support the use of arnica?
Mixed evidence but can be provided if there are no cautions or contraindications
How does witch hazel (Hamamelis) work to reduce bruising?
Acts as an astringent and tightens pores and blood vessels to reduce blood flow
What conditions are potentially caused by bursitis?
Housemaid’s knee (front of knee)
Baker’s cyst (back of knee)
Student’s elbow
Pain the the back of the heel
Pain under heel (NOT plantar fasciitis)
